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Based on record review and interview, the facility staff failed to implement immediate actions outlined in the water management plan in response to a suspected case of hospital acquired legionella for 1 of 1 patients (Patient #1), and failed to identify mitigation opportunities to reduce the risk of growth of pathogens in 1 of 1 water management plan.

Findings Include:

A review of the "Water Management Plan" last revised 2/2024 revealed, "[Facility M] has developed and implemented a water management plan to ensure the safety of its water sources at the hospital and clinic in [Facility M.] Elements of the plan are based on the guidance of the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) publication "Water Management in Healthcare Facilities: Complying with ASHRAE standard 188" which references CDC (Centers for Disease Control and Prevention) guidelines and is in compliance with CMS directive QSO-17-30...
·5. Process for reporting and responding to a suspected case of Legionella:
a. [Facility M] have a suspected or verified case and cannot confirm its source (community based or facility based).
b. Parties from Infection Prevention, Facilities, Quality, Laboratory, and the discovering clinical team will meet to discuss possible exposure possibilities.
c. Decision may be made to test [Facility M] water sources that had been high likelihood for exposure/contact by that Individual (may be showers, spa, electric water coolers, etc.).
d. Determine through external sources the best options for decontamination of domestic water system. Include testing of city source water.
e. Activate incident command to manage the decontamination, notification, and resumption of normal services.
f. If Legionella is present in [Facility M] water system, immediately cease the use of water that may lead to breathing of aerosolized vapors, such as the use of water coolers, showers, spa...
g. Contact remediation firms that specialize in the discovery and abatement of Legionella in domestic water systems..."

On 2/26/25, Patient #1 was readmitted to Facility M with concerns for fever, hypotension, tachycardia, hypoxia, and cough. On 2/26/25 Patient #1's urine antigen test resulted positive for Legionella. Patient #1 was treated with Azithromycin (antibiotic that treats Legionella Pneumonia), and discharged in a stable condition to Facility N on 3/3/2025.

A review of Facility M's Legionella tracking timeline revealed the following:
·2/27/25: Facility M received Patient #1's positive Legionella test results.
·2/28/25: Infection Preventionist RN F reported Patient #1's positive Legionella test result to WEDSS (Wisconsin Electronic Disease Surveillance System).
There was no evidence that incident command was implemented per the water management plan or further notifications and communication was completed.

On 3/12/25: Water samples were collected by the State Department of Public Health and County Health Department P. The Facility was notified the water tested positive for Legionella on 3/20/25.

On 3/17/25 leadership met to review "logistics for remediation strategies including hyper-chlorination and subsequent water shut down, mass flushing, filtration and ongoing testing." There was no evidence of actions taken as a result of this meeting.

On 4/1/25 (33 days after Patient #1 tested positive and 20 days after Water Testing Results) the facility began flushing of faucets throughout the facility.

·4/4/25: Signage was added to Facility M entrances notifying of Legionella in water. Point of use filters added to sinks in patient care areas and public restrooms. Signs were added to sinks without filters notifying users that sink does not have point of use filter.

An interview was conducted on 4/8/25 at 2:00 PM with Infection Preventionist F. Infection Preventionist F stated that the action he took immediately following the notification of Patient #1's positive Legionella result was to report it to Director of Quality D and to enter it in the WEDSS system. Infection Preventionist F stated that he did not take any other action until he received notification from County Health Department P.

Based on record review, interview and observation the facility failed to disinfect the water system by thermal or other disinfection method when the facility's water tested positive for Legionella in 1 of 1 hot water system supply. The facility also failed to maintain hot water temperatures for prevention of future Legionella outbreaks.

Based on record review, interview and observation the facility failed to disinfect the water system by thermal or other disinfection method when tested positive for Legionella and failed to maintain hot water temperatures for prevention of Legionella in 1 of 1 hot water system supply.

A review of State Plumbing Code 382.50(3)(ag), 382.50(3)(b)(6) revealed that hot water supply temperature to be initiated and stored at 140 deg F in holding tank. Return water temperature is to be a minimum of 124 deg F.

A review of ASHRAE 12 guidelines revealed, recommend 140 deg F supply and return water temperature of 124 deg F.

Findings Include:

Review of the facility Water Management Plan (WMP) revealed that the facility did not have a policy that provides for the temperature of hot water supply at the source i.e. starting point of hot water distribution piping based on CDC and ASHRAE 12 guidelines to maintain hot water circulation in distribution piping above a certain minimum to reduce the risk of growth of pathogens including the growth of legionella bacteria. Alternatively, the WMP did not provide for a disinfectant system to treat municipal water entering the building in accordance with CDC and ASHRAE.

On 2/26/25, Patient #1 was readmitted to Facility M with concerns for fever, hypotension, tachycardia, hypoxia, and cough. On 2/26/25 Patient #1's urine antigen test resulted positive for Legionella. Patient #1 was treated with Azithromycin (antibiotic that treats Legionella Pneumonia), and discharged home in a stable condition to Facility N on 3/3/2025.

On 3/12/25: Water samples were collected by the State Department of Public Health and County Health Department P. The Facility was notified the water tested positive for Legionella on 3/20/25.

The facility failed to disinfect the domestic hot water system piping and fixtures based on CDC and ASHRAE 12 guidelines - raising the hot water temperature to a recommended high and maintaining at that level while progressively flushing each outlet around the system, chlorination followed by flushing, or other approved disinfectant system. Recolonization is possible unless proper hot water temperature is maintained in the distribution piping, or if subsequent periodic chlorination is not carried out per ASHRAE 12 guidelines.

On 04/08/2025 between 10 AM and 2 PM, observation, record review and staff interview revealed that the temperature gauge in the outlet pipe of hot water mixing valve in the mechanical room read water temperature of 118 deg F. The hot water at 118 deg F was supplied to the distribution line serving the 1972 building housing patient sleeping areas and treatment areas. Water returned to the holding tank in the mechanical room at 112 deg F - the temperature reading at temperature gauge in the return line to building. Review of hot water supply temperature log between 1:30 PM and 2:15 PM revealed that the hot water temperature supplied to 1972 building varied from 116 to 120 deg F.

The above water temperature readings were confirmed by interview with Director of Facilities G, and Infection Preventionist RN F at the time of discovery.

In an interview on 04/14/2025 at 11:27 A.M. State Legionella Hygiene Specialist J stated that because there has been an outbreak recently in the facility, it can be concluded that Facility M's WMP did not provide for adequate control of the legionella bacteria in the hospital domestic hot water plumbing system by implementing proper remediation method in accordance with State Plumbing Code SPS 382.50 and ASHRAE 12 and CDC guidelines. Facility M failed to disinfect the water system by thermal or disinfection method when the Legionella outbreak was discovered.